Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients

Can early serum lipase measurement be routinely implemented to rule out clinically significant pancreatic fistula after pancreaticoduodenectomy?

INTRODUCTION

Postoperative pancreatic fistula (POPF) is the most significant cause of morbidity and mortality after pancreaticoduodenectomy (PD). We evaluated the role of postoperative serum lipase concentration in ruling out POPF in the immediate post-operative period.

MATERIALS AND METHODS

We retrospectively analysed 98 consecutive PD performed between January 2009 and December 2014, investigating the correlation between postoperative day 1 (POD1) serum lipase concentration and POPF development.

RESULTS

29 patients (29.5%) developed POPF [grade A, 17 (17.3%); grade B, 8 (8.1%); grade C, 4 (4%)]. A receiver operating characteristic (ROC) analysis was conducted to determine the threshold value of POD1 serum lipase associated with clinically significant POPF (AUC = 0.76, 95% CI 0.64-0.86, P = 0.01). Such threshold was ≤ 44.5 U/L and its sensitivity and specificity were 92% and 66%, respectively. The positive and negative predictive values (PPV, NPV) were 31% and 98%, respectively.

CONCLUSION

Early routinely measurement of serum lipase proved to be helpful in ruling out clinically relevant POPF (CR-POPF). In our cohort, a POD1 cut-off of ≤ 44.5 U/L allowed early and accurate identification of patients with low probability to develop clinically significant POPF, who can eventually be selected for enhanced post-operative recovery with significant clinical and economic benefits.

Can the measurement of amylase in drain after distal pancreatectomy predict post-operative pancreatic fistula?

INTRODUCTION

The most frequent reason for performing a distal pancreatectomy is the presence of cystic or neuroendocrine tumors, in which the distal pancreatic stump is often soft and non fibrotic. This parenchymal consistence represents the main risk factor for post-operative pancreatic fistula. In order to identify the fistula and assessing its severity postoperative monitoring of amylase from intraperitoneal drains is important.

METHODS

From a retrospective multicentric database analysis were included 33 patients who underwent distal pancreatectomy for pancreatic neoplastic disease.

RESULTS

Postoperative pancreatic fistula occurred in four cases. One patient had a ductal adenocarcinoma, two presented with pancreatic endocrine neoplasms and the last one had an intraductal papillary mucinous neoplasia. Two patients underwent open, the other two laparoscopic distal pancreatectomy.

DISCUSSION

Postoperative pancreatic fistulas after distal pancreatectomy worsen the quality of life, prolong the post-operative stay and delay further adjuvant therapy. In patients who underwent distal pancreatectomy literature exposed some advantages deriving from the placement of abdominal drainages only in selected cases and from their early removal. Patients presenting a high risk of pancreatic fistula had higher amylase levels of drainage fluid in the first postoperative day.

CONCLUSION

POPF is the most frequently complication after pancreatectomy. In our analysis DFA1>5000 can be considered as a predictive factor for pancreatic fistula. For this reason, the systematic measurement of amylase in drain fluid in first-postoperative day can be considered a good clinical practice.

Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy

OBJECTIVE

Prior studies suggested that early drain removal prevented the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD), but there has been no corresponding prospective trial for distal pancreatectomy (DP). The purpose of this study was to determine the safety and efficacy of early drain removal and triple-drug therapy (TDT) with gabexate mesilate, octreotide and carbapenem antibiotics to prevent PF after DP in patients at high-risk of developing PF.

METHODS

A total 71 patients who underwent a DP were enrolled. We prospectively divided them into two groups: the late-removal group, in which the drain remained in place for at least for 5 days postoperatively (n = 30) and the early-removal group in which the drain was removed on postoperative day 1 (POD1) (n = 41). For the patients with a high drain amylase level (≥10,000 IU/L) and patients with symptomatic intraperitoneal fluid collection, our original TDT was introduced. The primary endpoint was the safety and efficacy of this management, and the secondary endpoint was the incidence of PF.

RESULTS

The incidence of clinical PF was significantly lower in the early-removal group (0% vs. the late removal 16%; p < 0.001). In the early-removal group, TDT was administered to 12 patients (29%) and none of the patients needed additional treatment after TDT.

CONCLUSIONS

Postoperative management after DP with early drain removal and TDT was safe and effective for preventing PF.

Risk scoring system and predictor for clinically relevant pancreatic fistula after pancreaticoduodenectomy

AIM: To establish a scoring system to predict clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD).

METHODS: The clinical records of 921 consecutive patients who underwent PD between 2008 and 2013 were reviewed retrospectively. Postoperative pancreatic fistula (POPF) was defined and classified by the international study group of pancreatic fistula (ISGPF). We used a logistic regression model to determine the independent risk factors of CR-POPF and developed a scoring system based on the regression coefficient of the logistic regression model. The optimal cut-off value to divide the risk strata was determined by the Youden index. The patients were divided into two groups (low risk and high risk). The independent sample t test was used to detect differences in the means of drain amylase on postoperative day (POD) 1, 2 and 3. The optimal cut-off level of the drain amylase to distinguish CR-POPF from non-clinical POPF in the two risk strata groups was determined using the receiver operating characteristic (ROC) curves.

RESULTS: Grade A POPF occurred in 106 (11.5%) patients, grade B occurred in 57 (6.2%) patients, and grade C occurred in 32 (3.5%) patients. A predictive scoring system for CR-POPF (0-6 points) was constructed using the following four factors: 1 point for each body mass index ≥ 28 [odds ratio (OR) = 3.86; 95% confidence interval (CI): 1.92-7.75, P = 0.00], soft gland texture (OR = 4.50; 95%CI, 2.53-7.98, P = 0.00), and the difference between the blood loss and transfusion in operation ≥ 800 mL (OR = 3.45; 95%CI, 1.92-7.75, P = 0.00); and from 0 points for a 5 mm or greater duct diameter to 3 points for a less than 2 mm duct (OR = 8.97; 95%CI: 3.70-21.77, P = 0.00). The ROC curve showed that the area under the curve of this score was 0.812. A score of 3 points was suggested to be the best cut-off value (Youden index = 0.485). In the low risk group, a drain amylase level ≥ 3600 U/L on POD3 could distinguish CR-POPF from non-clinical POPF (the sensitivity and specificity were 75% and 85%, respectively). In the high risk group, the best cut-off was a drain amylase level of 1600 (the sensitivity and specificity were 77 and 63%, respectively).

CONCLUSION: A 6-point scoring system accurately predicted the occurrence of CR-POPF. In addition, a drain amylase level on POD3 might be a predictor of this complication.

DRAPA trial--closed-suction drains versus closed gravity drains in pancreatic surgery: study protocol for a randomized controlled trial

BACKGROUND

The morbidity of pancreatic resection remains high, with pancreatic fistula being the most common cause. The important question is whether any postoperative treatment adjustment may prevent the development of clinically significant postoperative pancreatic fistulae. Recent studies have shown that intraabdominal drains and manipulation using them are of great importance. Although authors of a few retrospective reports have described good results of pancreatic resection without the use of intraabdominal drains, a recent prospective randomized trial showed that routine elimination of drains in pancreaticoduodenectomy is associated with poor outcome. An important issue arises as to which type of drain is most suitable for pancreatic resection. Two types of surgical drains exist: open drains and closed drains. Open drains are considered obsolete nowadays because of frequent retrograde infection. Closed drains include two types: passive gravity drains and closed-suction drains. Closed-suction drains are more effective, as they remove fluid from the abdominal cavity under light pressure. However, some surgeons believe that closed-suction drains represent a potential hazard to patients and that negative pressure might increase the risk of pancreatic fistulae. Nobody has yet specifically dealt with the question of which kind of drainage is most appropriate in pancreatic surgery.

METHODS/DESIGN

The aim of the DRAins in PAncreatic surgery (DRAPA) trial is to compare the closed-suction drain versus the closed passive gravity drain in pancreatic resection. DRAPA is a dual-centre, prospective, randomized controlled trial. The primary endpoint is the rate of postoperative pancreatic fistula; the secondary endpoint is postoperative morbidity with follow-up of 3 months.

DISCUSSION

No study to date has compared different types of drains in pancreatic surgery. This study is designed to answer the question whether any particular type of drain might lower the rate of postoperative pancreatic fistula or other complications.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01988519. Registered 13 November 2013.

Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase

INTRODUCTION

The safety and feasibility of an enhanced recovery pathway (ERP) after pancreatic surgery is largely unknown. Our aim was to prospectively evaluate a targeted ERP after pancreaticoduodenectomy (PD), using first postoperative day (POD) drain fluid amylase (DFA1) values to identify patients at low risk of pancreatic fistula (PF).

PATIENTS AND METHODS

Non-randomized cohort study of 130 consecutive patients. Perioperative outcomes were compared before (pre-ERP; N=65) and after (post-ERP; N=65) implementation of an ERP. Patients in each group were stratified according to the risk of PF using DFA1<350 IU/l. Low-risk patients in the post-ERP group were selected for early oral intake and early drain removal.

RESULTS

81/130 patients had a DFA1<350. Incidence of PF was significantly lower in low-risk patients (9 vs. 45%, P=0.0001). In low-risk patients, morbidity (43 vs. 36%) and mortality (2.7 vs. 4.5%) were similar for both pre- and post-ERP patients. Hospital stay (median 9 vs. 7 days, P=0.03) and 30-day readmissions (17 vs. 2%, P=0.04) were lower in low-risk patients in the post-ERP group. In high-risk patients, there was no difference in outcomes between pre- and post-ERP.

CONCLUSION

Patients at low risk of PF after PD can be identified by first POD DFA1. Enhanced recovery after PD is safe and leads to improved short-term outcomes in low-risk patients.

Division of surgeon workload in pancreaticoduodenectomy: striving to decrease post-operative pancreatic fistula

BACKGROUND

Many studies have reported factors affecting pancreatic leakage after pancreaticoduodenectomy (PD), but there have been few reports on surgeon workload and post-operative pancreatic fistula (POPF). This study was conducted to explore whether a surgeon's workload during PD impacts the occurrence of POPF.

METHODS

We retrospectively analysed 270 consecutive patients who underwent PD between January 2008 and June 2013 by a single experienced surgeon. These patients were divided into those who underwent PD entirely by a single operator (group 1) and those who received reconstructions by other operators (group 2). Duct-to-mucosa pancreaticojejunostomy was performed on all patients. The International Study Group on Pancreatic Fistula criteria were used to define POPF.

RESULTS

There were 157 patients (58.1%) in group 1 and 113 patients (41.9%) in group 2. The post-operative morbidity rate was comparable between the two groups (55.4% versus 52.2%; P = 0.603), but the clinical pancreatic fistula (grade B/C) rate was significantly different (10.8% versus 2.7%; P = 0.011). The overall post-operative mortality was one patient (0.4%). Significant associations were found between clinical pancreatic fistulas and soft pancreas texture (P = 0.021), preoperative serum albumin level ≤3.5 g/dL (P = 0.012), other pathology besides pancreatic cancer (P = 0.027) and a single-operator procedure (P = 0.019). A multivariate logistic regression analysis revealed that a single operator (odds ratio: 4.2, P = 0.029) was a significant predictive risk factor for clinically relevant POPF.

CONCLUSION

Dividing the surgeon's workload in PD is associated with lower rates of POPF.

Limited utility of inflammatory markers in the early detection of postoperative inflammatory complications after pancreatic resection: Cohort study and meta-analyses

PURPOSE

To examine the diagnostic accuracy of systemic inflammatory markers in early prediction of inflammatory postoperative complications (IPC) and clinically-relevant pancreatic fistula (PF).

METHODS

Preoperative and postoperative [until postoperative day (POD) 4)] measurements of hemoglobin, white blood cell counts (WBC), neutrophil/lymphocyte ratio (NLR) and C-reactive protein (CRP) were correlated with IPC and PF. Meta-analyses of biochemical predictors were performed.

RESULTS

Ninety-two out of 378 patients developed IPC, PF occurred in 31. Preoperative WBC (OR 1.0001, 95% CI: 1.0001-1.0002, p = 0.02), NLR on POD2 (OR 1.05, 95% CI: 1.006-1.1, p = 0.02) and CRP on POD4 (OR 1.006, 95% CI: 1.002-1.01, p = 0.02) predicted IPC at multivariate analysis. The model including these three variables showed a diagnostic accuracy of 76.8% (sensitivity 20, specificity 97%.14; PPV 71.43, PPN 77.27) and, at logistic regression analysis an OR of 8.5 (95% CI: 2.5-28.6, p < 0.001). Only CRP >272 on POD3 (OR 3.32, 95% CI: 1.46-7.52, p = 0.003) was associated with PF with a diagnostic accuracy of 74% (sensitivity 54.5, specificity 78.5; PPV 16.88, NPV 94.25). Meta-analyses of available data suggested sensitivity of 75.3% (95% CI 66.7-82.6) and specificity of 75.5% (95% CI 61.3-85.7). However, these studies were significantly heterogeneous.

CONCLUSIONS

Readily available, routine tests have limited utility in predicting IPC. Further research is required to develop novel biomarkers to aid management of these patients.

Prophylactic intra-peritoneal drain placement following pancreaticoduodenectomy: A systematic review and meta-analysis

AIM: To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy (PD) with or without prophylactic drainage.

METHODS: Relevant comparative randomized and non-randomized studies were systemically searched based on specific inclusion and exclusion criteria. Postoperative outcomes were compared between patients with and those without routine drainage. Pooled odds ratios (OR) with 95%CI were calculated using either fixed effects or random effects models.

RESULTS: One randomized controlled trial and four non-randomized comparative studies recruiting 1728 patients were analyzed. Patients without prophylactic drainage after PD had significantly higher mortality (OR = 2.32, 95%CI: 1.11-4.85; P = 0.02), despite the fact that they were associated with fewer overall complications (OR = 0.62, 95%CI: 0.48-0.82; P = 0.00), major complications (OR = 0.75, 95%CI: 0.60-0.93; P = 0.01) and readmissions (OR = 0.77, 95%CI: 0.60-0.98; P = 0.04). There were no significant differences in the rates of pancreatic fistula, intra-abdominal abscesses, postpancreatectomy hemorrhage, biliary fistula, delayed gastric emptying, reoperation or radiologic-guided drains between the two groups.

CONCLUSION: Indiscriminate abandonment of intra-abdominal drainage following PD is associated with greater mortality, but lower complication rates. Future randomized trials should compare routine vs selective drainage.

Application of air insufflation to prevent clinical pancreatic fistula after pancreaticoduodenectomy

AIM: To introduce an air insufflation procedure and to investigate the effectiveness of air insufflation in preventing pancreatic fistula (PF).

METHODS: From March 2010 to August 2013, a total of 185 patients underwent pancreaticoduodenectomy (PD) at our institution, and 74 patients were not involved in this study for various reasons. The clinical outcomes of 111 patients were retrospectively analyzed. The air insufflation test was performed in 46 patients to investigate the efficacy of the pancreaticojejunal anastomosis during surgery, and 65 patients who did not receive the air insufflation test served as controls. Preoperative assessments and intraoperative outcomes were compared between the 2 groups. Univariate and multivariate analyses were performed to identify the risk factors for PF.

RESULTS: The two patient groups had similar baseline demographics, preoperative assessments, operative factors, pancreatic factors and pathological results. The overall mortality, morbidity, and PF rates were 1.8%, 48.6%, and 26.1%, respectively. No significant differences were observed in either morbidity or mortality between the two groups. The rate of clinical PF (grade B and grade C PF) was significantly lower in the air insufflation test group, compared with the non-air insufflation test group (6.5% vs 23.1%, P = 0.02). Univariate analysis identified the following parameters as risk factors related to clinical PF: estimated blood loss; pancreatic duct diameter ≤ 3 mm; invagination anastomosis technique; and not undergoing air insufflation test. By further analyzing these variables with multivariate logistic regression, estimated blood loss, pancreatic duct diameter ≤ 3 mm and not undergoing air insufflation test were demonstrated to be independent risk factors.

CONCLUSION: Performing an air insufflation test could significantly reduce the occurrence of clinical PF after PD. Not performing an air insufflation test was an independent risk factor for clinical PF.

Pancreatic fistulae secondary to trypsinogen activation by Pseudomonas aeruginosa infection after pancreatoduodenectomy

BACKGROUND

Pancreatic fistula after pancreatoduodenectomy (PD) is associated with high mortality and morbidity. Trypsinogen activation and bacteria, although hypothesized to be interrelated etiopathogenetically, have not had their relationship and pathogenic mechanisms elucidated. This study investigated bacterial involvement in pancreatic juice activation perioperatively after PD at sites of pancreatic fistula formation.

METHODS

Fifty patients underwent PD; postoperative pancreatic fistulae were graded based on the International Study Group for Pancreatic Fistula grading criteria. Bacteria were isolated from cultures of drainage fluid. Digested peptides from trypsinogen and bacterial culture supernatants underwent sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) separation and mass spectrometric analysis. Zymography was used to detect the trypsinogen activator.

RESULTS

Pseudomonas aeruginosa and Enterobacter cloacae isolated from drainage fluid in patients with grades B and C pancreatic fistulae could cause trypsinogen activation. Trypsinogen activation by P. aeruginosa and E. cloacae were preventable by the use of a serine protease inhibitor in vitro. A protease in the supernatant from P. aeruginosa-positive cultures acted as the trypsinogen activator.

CONCLUSIONS

Infection with P. aeruginosa perioperatively to PD entails secretion of a protease activator of trypsinogen to trypsin. Bacterial infection control in the perioperative PD period could be crucial to prevent development of pancreatic fistula.

The value of drains as a fistula mitigation strategy for pancreatoduodenectomy: something for everyone? Results of a randomized prospective multi-institutional study

BACKGROUND

A recent randomized, controlled trial investigating intraperitoneal drain use during pancreatoduodenectomy (PD) had a primary goal of assessing overall morbidity. It was terminated early with findings that routine elimination of drains in PD increases mortality and the severity and frequency of overall complications. Here, we provide a follow-up analysis of drain value in reference to clinically relevant postoperative pancreatic fistula (CR-POPF).

METHODS

Nine institutions performed 137 PDs, with patients randomized to intraperitoneal drainage (N = 68) or no drainage (N = 69). The Fistula Risk Score (FRS), a 10-point scale derived from four validated risk factors for CR-POPF, facilitated risk adjustment between treatment groups.

RESULTS

There was no difference in fistula risk between the two cohorts. Overall, CR-POPF rates were higher in the no drain group compared to the drain group (20.3 vs. 13.2%; p = 0.269). Patients with negligible/low FRS risk had higher rates of CR-POPF when drains were used (14.8 vs. 4.0%; p = 0.352). Conversely, there were significantly fewer CR-POPFs (12.2 vs. 29.5%; p = 0.050) when drains were used with moderate/high risk patients. Lastly, moderate/high risk patients who suffered a CR-POPF had reduced 90-day mortality (22.2 vs. 42.9%) when a drain was used.

CONCLUSION

The results of this analysis suggest that drains diminish the rate and severity of CR-POPF in patients with moderate/high risk, but they could possibly be avoided in the roughly one third of patients with negligible/low risk.

Negative predictive value of drain amylase concentration for development of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Post-operative pancreatic fistula (POPF) is the major source of morbidity following pancreaticoduodenectomy. A predictive indicator would be highly advantageous. One potential marker is drain amylase concentration (DAC). However, its predictive value has not been fully established.

METHODS

405 patients undergoing pancreaticoduodenectomy at our centre over a 10 year period were reviewed to determine the value of DAC as a predictive indicator for the development of POPF.

RESULTS

POPF developed in 58 patients (14%). These patients suffered greater morbidity. Overall 30-day mortality was 1.5%. Male gender (OR: 5.1; p = 0.0082) and age > 70 (OR 2; p = 0.0372) were independent risk factors for POPF, whilst Type 2 diabetes (OR: 0.2321; p = 0.0090) and pancreatic ductal-adenocarcinoma (OR: 0.3721; p = 0.0039) decreased POPF risk. The DACs post-operatively were significantly higher in those developing POPF, but with significant overlap. ROC curves revealed optimal threshold values for differentiating POPF and non-POPF patients. A DAC°<°1400 U/ml on day 1 and <768 U/ml on day 2, although having a poor positive predictive value (32-44%), had a very strong negative predictive value (97-99%).

CONCLUSION

Our data suggest that post-operative DAC below the determined optimal threshold values on day 1 and 2 following pancreaticoduodenectomy carries high negative predictive value for POPF development and identifies patients in whom early drain removal, and enhanced recovery may be considered, with simultaneous assessment of operative and clinical factors.

Morbidity, mortality, cost, and survival estimates of gastrointestinal anastomotic leaks

BACKGROUND

Anastomotic leak, a potentially deadly postoperative occurrence, particularly interests surgeons performing gastrointestinal procedures. We investigated incidence, cost, and impact on survival of anastomotic leak in gastrointestinal surgical procedures at an academic center.

STUDY DESIGN

We conducted a chart review of American College of Surgeons NSQIP operative procedures with gastrointestinal anastomosis from January 1, 2003 through April 30, 2006. Each case with an American College of Surgeons NSQIP 30-day postoperative complication was systematically reviewed for evidence of anastomotic leak for 12 months after the operative date. We tracked patients for up to 10 years to determine survival. Morbidity, mortality, and cost for patients with gastrointestinal anastomotic leaks were compared with patients with anastomoses that remained intact.

RESULTS

Unadjusted analyses revealed significant differences between patients who had anastomotic leaks develop and those who did not: morbidity (98.0% vs. 28.4%; p < 0.0001), length of stay (13 vs. 5 days; p ≤ 0.0001), 30-day mortality (8.4% vs. 2.5%; p < 0.0001), long-term mortality (36.4% vs. 20.0%; p ≤ 0.0001), and hospital costs (chi-square [2] = 359.8; p < 0.0001). Multivariable regression demonstrated that anastomotic leak was associated with congestive heart failure (odds ratio [OR] = 31.5; 95% CI, 2.6-381.4; p = 0.007), peripheral vascular disease (OR = 4.6; 95% CI, 1.0-20.5; p = 0.048), alcohol abuse (OR = 3.7; 95% CI, 1.6-8.3; p = 0.002), steroid use (OR = 2.3; 95% CI: 1.1-5.0; p = 0.027), abnormal sodium (OR = 0.4; 95% CI, 0.2-0.7; p = 0.002), weight loss (OR = 0.2; 95% CI, 0.06-0.7; p = 0.011), and location of anastomosis: rectum (OR = 14.0; 95% CI, 2.6-75.5; p = 0.002), esophagus (OR = 13.0; 95% CI, 3.6-46.2; p < 0.0001), pancreas (OR = 12.4; 95% CI, 3.3-46.2; p < 0.0001), small intestine (OR = 6.9; 95% CI, 1.8-26.4; p = 0.005), and colon (OR = 5.2; 95% CI, 1.5-17.7; p = 0.009).

CONCLUSIONS

Significant morbidity, mortality, and cost accompany gastrointestinal anastomotic leaks. Patients who experience an anastomotic leak have lower rates of survival at 30 days and long term.

Low drain fluid amylase predicts absence of pancreatic fistula following pancreatectomy

INTRODUCTION

Improvements in the ability to predict pancreatic fistula could enhance patient outcomes. Previous studies demonstrate that drain fluid amylase on postoperative day 1 (DFA1) is predictive of pancreatic fistula. We sought to assess the accuracy of DFA1 and to identify a reliable DFA1 threshold under which pancreatic fistula is ruled out.

METHODS

Patients undergoing pancreatic resection from November 1, 2011 to December 31, 2012 were selected from the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project database. Pancreatic fistula was defined as drainage of amylase-rich fluid with drain continuation >7 days, percutaneous drainage, or reoperation for a pancreatic fluid collection. Univariate and multi-variable regression models were utilized to identify factors predictive of pancreatic fistula.

RESULTS

DFA1 was recorded in 536 of 2,805 patients who underwent pancreatic resection, including pancreaticoduodenectomy (n = 380), distal pancreatectomy (n = 140), and enucleation (n = 16). Pancreatic fistula occurred in 92/536 (17.2%) patients. DFA1, increased body mass index, small pancreatic duct size, and soft texture were associated with fistula (p < 0.05). A DFA1 cutoff value of <90 U/L demonstrated the highest negative predictive value of 98.2%. Receiver operating characteristic (ROC) curve confirmed the predictive relationship of DFA1 and pancreatic fistula.

CONCLUSION

Low DFA1 predicts the absence of a pancreatic fistula. In patients with DFA1 < 90 U/L, early drain removal is advisable.

Surgical treatment of the pancreatic stump: preventive strategies of pancreatic fistula after pancreatoduodenectomy for cancer

BACKGROUND

The institutions with high volume of pancreatic surgery report morbidity rate from 30% to 50% and mortality less than 5% after pancreaticoduodenectomy (PD). At the present, the most significant cause of morbidity and mortality is pancreatic fistula (PF).

AIM

The purpose of the study is to identify the most important clinical factors which may predict PF development and eventually suggest alternative approaches to the pancreatic stump management.

PATIENTS AND METHODS

A retrospective analysis of a clinical data base of a tertiary care Hospital was performed. From 2002 to 2012 a single Surgeon prospectively performed 150 pancreaticoduodenectomies for cancer. Four different techniques were used: end to end pancreaticojejunostomy, end to side pancreaticojejunostomy, pancreatic duct occlusion and duct to mucosa anastomosis. The intraoperative gland texture was classified as soft, firm and hard. The duct size was preoperatively (CT scan) and intraoperatively recorded and classified: < 3 mm small, 3-6 mm medium, > 6 mm large. The histopathological characteristic of the gland fibrosis was graduate as low 1, moderate 2, high 3.

CONCLUSION

Relationships between pre and intraoperative duct size measurement, pancreatic texture and pancreatic fibrosis grading were highly significant. Small duct and soft pancreas with low grade fibrosis are the most important risk factors for pancreatic fistula development. The proper selection of pancreatic stump management or the decision to refer the high risk patients to high volume Center can be suggested by the elevated correspondence of pre and intraoperative duct diameter with the related pancreatic fibrosis grade and gland consistency. Preoperative assessment of the pancreatic duct makes possible to predict the risk of pancreatic fistula.

Drain amylase value as an early predictor of pancreatic fistula after cephalic duodenopancreatectomy

AIM: To determine predictors of clinically relevant pancreatic fistulas (CRPF) by measuring drain fluid amylase (DFA) in the early postoperative period.

METHODS: This prospective clinical study included 382 patients with periampullary tumors that were surgically resected at our department between March 2005 and October 2012. A cephalic duodenopancreatectomy (DP) was performed on all patients. Two closed suction drains were placed at the end of the surgery. The highest postoperative DFA value was recorded and analyzed during the first three postoperative days and on subsequent days if the drains were kept longer. Pancreatic fistula (PF) was classified according to the International Study Group of Pancreatic Fistula (ISGPF) criteria. Postoperative complications were defined according to the Dindo-Clavien classification. All data were statistically analyzed. The optimal thresholds of DFA levels on the first, second and third postoperative days were estimated by constructing receiver operating curves, generated by calculating the sensitivities and specificities of the DFA levels. The DFA level limits were used to differentiate between the group without PF and the groups with biochemical pancreatic fistula (BPF) and CRPF.

RESULTS: Pylorus-preserving duodenopancreatectomy was performed on 289 (75.6%) patients, while the remaining patients underwent a classic Whipple procedure (CW). The total incidence of PF was 37.7% (grade A 22.8%, grade B 11.0% and grade C 3.9%). Soft pancreatic texture (SPT) was present in 58.3% of patients who developed PF. Mortality was 4.2%. The median DFA value on the first postoperative day (DFA1) in patients who developed PF was 4520 U/L (range 350-99000 U/L) for grade A fistula (BPF) with a SPT and a diameter of the main pancreatic duct (MPD) of ≤ 3 mm. For grade B/C (CRPF), the median DFA1 value was 8501 U/L (range 377-92060 U/L) with a SPT and MPD of ≤ 3 mm. These values were significantly higher when compared to the patients who did not have PF (122; range 5-37875 U/L). The upper limit of DFA values for the first 3 postoperative days in the examined stages of PF were: DFA1 1200 U/L for the BPF and CRPF; DFA3 350 U/L for BPF and DFA3 800 U/L for CRPF. The determined values were highly significant and demonstrated a reliable diagnostic test for both BPF and CRPF.

CONCLUSION: DFA1 ≥ 1200 U/L is an important predictive factor for PF of any degree. The trend of DFA3 (decrease of < 50%) compared to DFA1 is a significant factor in the differentiation of CRPF from transient BPF.

Is routine drainage necessary after pancreaticoduodenectomy?

With the development of imaging technology and surgical techniques, pancreatic resections to treat pancreatic tumors, ampulla tumors, and other pancreatic diseases have increased. Pancreaticoduodenectomy, one type of pancreatic resection, is a complex surgery with the loss of pancreatic integrity and various anastomoses. Complications after pancreaticoduodenectomy such as pancreatic fistulas and anastomosis leakage are common and significantly associated with patient outcomes. Pancreatic fistula is one of the most important postoperative complications; this condition can cause intraperitoneal hemorrhage, septic shock, or even death. An effective way has not yet been found to avoid the occurrence of pancreatic fistula. In most medical centers, the frequency of pancreatic fistula has remained between 9% and 13%. The early detection and routine drainage of anastomotic fistulas, pancreatic fistulas, bleeding, or other intra-abdominal fluid collections after pancreatic resections are considered as important and effective ways to reduce postoperative complications and the mortality rate. However, many recent studies have argued that routine drainage after abdominal operations, including pancreaticoduodenectomies, does not affect the incidence of postoperative complications. Although inserting drains after pancreatic resections continues to be a routine procedure, its necessity remains controversial. This article reviews studies of the advantages and disadvantages of routine drainage after pancreaticoduodenectomy and discusses the necessity of this procedure.

Serum amylase on the night of surgery predicts clinically significant pancreatic fistula after pancreaticoduodenectomy

OBJECTIVES

Drainage after pancreaticoduodenectomy (PD) remains controversial because the risk for uncontrolled postoperative pancreatic fistula (POPF) must be balanced against the potential morbidity associated with prolonged and possibly unnecessary drainage. This study investigated the utility of the level of serum amylase on the night of surgery [postoperative day (PoD) 0 serum amylase] to predict POPF.

METHODS

A total of 185 patients who underwent PD were studied. Occurrences of POPF were graded using the International Study Group on Pancreatic Fistula (ISGPF) classification. Receiver operating characteristic (ROC) analysis identified a threshold value of PoD 0 serum amylase associated with clinically significant POPF (ISGPF Grades B and C) in a test cohort (n = 45). The accuracy of this threshold value was then tested in a validation cohort (n = 140).

RESULTS

Overall, 43 (23.2%) patients developed clinically significant POPF. The threshold value of PoD 0 serum amylase for the identification of clinically significant POPF was ≥ 130 IU/l (P = 0.003). Serum amylase of <130 IU/l had a negative predictive value of 88.8% for clinically significant POPF (P < 0.001). Serum amylase of ≥ 130 IU/l on PoD 0 and a soft pancreatic parenchyma were independent risk factors for clinically significant POPF.

CONCLUSIONS

Postoperative day 0 serum amylase of <130 IU/l allows for the early and accurate categorization of patients at least risk for clinically significant POPF and may identify patients suitable for early drain removal.

Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy (PD) is associated with a high incidence of postoperative complications including pancreatic fistula. This randomized clinical trial compared the incidence of pancreatic fistula between the isolated Roux-en-Y (IsoRY) and conventional reconstruction (CR) methods.

METHODS

Patients admitted for PD between June 2009 and September 2012 in a single centre were assigned randomly to CR or IsoRY. The primary endpoint was the incidence of pancreatic fistula (grade A-C) defined according to the International Study Group on Pancreatic Fistula. Secondary endpoints were complication rates, mortality and hospital stay. Multiple logistic regression analysis was performed to identify factors associated with pancreatic fistula.

RESULTS

Some 153 patients were randomized, 76 to CR and 77 to IsoRY; two patients from the IsoRY group were excluded after randomization. Pancreatic fistula occurred in 26 patients (34 per cent) in the CR group and 25 (33 per cent) in the IsoRY group (P = 0·909). The number of patients with a clinically relevant pancreatic fistula (grade B or C) was similar in the two groups (10 and 11 patients respectively; P = 0·789), as were complication rates (42 versus 40 per cent; P = 0·793) and mortality (none in either group; P = 0·999). Soft pancreas was the only independent risk factor for pancreatic fistula (odds ratio 4·42, 95 per cent confidence interval 1·85 to 10·53; P <0·001).

CONCLUSION

This study showed that IsoRY reconstruction does not reduce the incidence of pancreatic fistula compared with CR.

REGISTRATION NUMBER

NCT00915863 (http://www.clinicaltrials.gov/) and UMIN000001967 (http://www.umin.ac.jp/).

Usefulness of drain amylase, serum C-reactive protein levels and body temperature to predict postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. Recently, early drain removal has been recommended as a means of preventing POPF. The present study sought to determine how to distinguish clinical POPF from non-clinical POPF in the early postoperative period after PD to aid in early drain removal.

METHODS

From March 2002 through December 2010, 176 patients underwent PD and were enrolled in this study to examine factors predictive of clinical POPF after PD. POPF was defined and classified according to the International Study Group of Pancreatic Surgery guideline, and grade B/C POPF was defined as clinical POPF.

RESULTS

Grade A POPF occurred in 39 (22.2 %) patients, grade B in 19 (10.8 %) patients, and grade C in 11 (6.3 %) patients. Clinical POPF (grade B/C) occurred in 17.1 % of patients. Multivariate analysis revealed male gender and body mass index (BMI) ≥22.5 kg/m(2) to be the independent preoperative risk factors predictive of POPF. Receiver operating characteristic curves showed that the combination of drain amylase ≥750 IU/L, C-reactive protein (CRP) ≥20 mg/dL, and body temperature ≥37.5 °C on postoperative day 3 could effectively distinguish clinical POPF from non-clinical POPF. Sensitivity, specificity, and accuracy were 84.6, 98.2, and 95.7 %, respectively.

CONCLUSIONS

Male gender and BMI ≥22.5 were the independent preoperative predictive risk factors for POPF. We assume that when amylase is <750 IU/L, serum CRP is <20 mg/dL, and body temperature is <37.5 °C the drain can safely be removed, even if POPF is indicated.

Amylase level in drains after pancreatoduodenectomy as a predictor of clinically significant pancreatic fistula

OBJECTIVES

Amylase level in drains (ALD) has been proposed as a predictor for the development of a clinically significant pancreatic fistula (CS-PF) in patients undergoing a major pancreatic surgery. This study aimed to determine if the ALD in patients who developed a CS-PF after pancreatoduodenectomy is higher than that for patients with transient fistulae and to establish a threshold value as a predictor of a CS-PF.

METHODS

From January 2002 to December 2012, all patients undergoing pancreatoduodenectomy were enrolled. At least 1 ALD measurement on postoperative day 3 was obtained. Pancreatic fistula (PF) was defined according to the International Study Group on Pancreatic Fistula. Both grade B and C PFs were considered as a CS-PF. We determined the cutoff value with a receiver operating characteristic curve.

RESULTS

A total of 135 patients were enrolled. Pancreatic fistula was diagnosed in 36 cases (26.7%). The ALD median values were the following: PF grade A, 1809 U/L; PF grade B, 19,710 U/L; and PF grade C, 27,590 U/L. A drain amylase value of 2820 U/L was determined to be the cutoff for the development of a CS-PF.

CONCLUSIONS

Patients with CS-PF have higher values of ALD than patients who developed a mild/transient fistula. An ALD higher than 2820 U/L identifies patients likely to present a CS-PF.

Is routine imaging necessary after pancreatic resection? An appraisal of postoperative ultrasonography for the detection of pancreatic fistula

OBJECTIVES

This study aimed to assess whether routine transabdominal ultrasonography (US) is clinically helpful for the early detection of postoperative pancreatic fistula (PF).

METHODS

In a prospective cohort of patients undergoing partial pancreatectomy, US was performed on postoperative day (POD) 3. Potential predictors of PF, including amylase value in drains (AVD) on POD 1, were investigated. A tree-based classification model of the independent predictors of PF was also performed.

RESULTS

One hundred seventy-three patients were analyzed. A peripancreatic collection on US and an AVD 5000 U/L or greater on POD 1 were predictors of PF. In the tree-based classification model, patients were stratified by AVD on POD 1. For values less than 5000 U/L (incidence of PF, 11.3%), US had a sensitivity of 23.1% and a specificity of 97.5%. For AVD 5000 U/L or greater (incidence of PF, 70.7%), sensitivity was 46.3% and specificity was 100%.

CONCLUSIONS

Despite the presence of a peripancreatic collection as a predictor of PF, US-as a diagnostic test-resulted to be highly specific but poorly sensitive even in the tree-based classification model. Therefore, its role does not seem to be clinically relevant and does not add value to AVD on POD 1, which remains the most powerful and relevant early predictor of PF.

Postoperative serum amylase predicts pancreatic fistula formation following pancreaticoduodenectomy

INTRODUCTION

Early identification of patients at risk for developing pancreatic fistula (PF) after pancreaticoduodenectomy (PD) may facilitate prevention or treatment strategies aimed at reducing its associated morbidity.

MATERIALS AND METHODS

A retrospective review of 176 consecutive PD performed between 2006 and 2011 was conducted in order to analyze the association between the serum amylase on postoperative day 1 (POD1) and the development of PF.

RESULTS

Serum amylase was recorded on POD1 in 146 of 176 PD cases (83.0 %). Twenty-seven patients (18.5 %) developed a postoperative PF: 6 type A, 19 type B, and 2 type C. Patients with a PF had a mean serum amylase on POD1 of 659 ± 581 compared to 246 ± 368 in those without a fistula (p < 0.001). On logistic regression, a serum amylase >140 U/L on POD1 was strongly associated with developing a PF (OR, 5.48; 95 % CI, 1.94-15.44). Sensitivity and specificity of a postoperative serum amylase >140 U/L was 81.5 and 55.5 %, respectively. Positive and negative predictive values were 29.3 and 93.0 %, respectively.

CONCLUSION

An elevated serum amylase on POD1 may be used, in addition to other prognostic factors, to help stratify risk for developing PF following PD.

Indicators for proper management of surgical drains following pancreaticoduodenectomy

BACKGROUND

The indicators for proper drain management following pancreaticoduodenectomy (PD) remain unclear. Our aim was to identify appropriate timing and proper indicators for safe drain management after PD.

METHODS

Prospectively collected data from 200 patients who underwent PD were evaluated. Postoperative clinical factors for clinically relevant pancreatic fistulas (CR-POPFs) and management of surgically placed drains were analyzed retrospectively.

RESULTS

CR-POPFs occurred in 8% of patients. By logistic regression analysis, one factor (non-serous fluid in the drain) on postoperative day (POD) 1 and two factors (non-serous fluid in the drain and serum CRP levels) on POD 3 and 4 were significantly associated with CR-POPFs. Receiver operating characteristic analysis demonstrated that combined predictive factors on POD 4 were the most accurate. Of 163 patients with serous fluid in the drain and CRP <15.6 mg/dl on POD 4, 1% had CR-POPFs, but no patient required POPF-related re-drainage. In contrast, among 37 patients with non-serous fluid in the drain or CRP levels ≥15.6 mg/dl, 35% had CR-POPFs, and 8% required POPF-related re-drainage.

CONCLUSIONS

A combination of CRP levels and the color of surgical drain fluid, not POD1 or 3, but on POD 4, may be the most accurate indicators for safe drain management following PD.

Operative drainage following pancreatic resection: analysis of 1122 patients resected over 5 years at a single institution

BACKGROUND

The only prospective randomized trial evaluating the use of intraperitoneal drainage following pancreatic resection was published from our institution approximately 10 years ago. The current study sought to evaluate the evolution of practice over the last 5 years.

PATIENTS AND METHODS

Between June 2006 and June 2011, there were 1122 resections performed. Six surgeons were evenly grouped and compared by practice pattern: routine drainers (drains placed > 95%), selective drainers, and routine nondrainers (drains placed ∼15%). Prospectively recorded preoperative, operative, and morbidity data were assessed in uni- and multivariate models.

RESULTS

Our operative drainage rate was 49% and decreased over time (62% 2006-2008 vs 37% 2009-2011, P < 0.001). Patients without operative drains had significantly lower grade ≥3 overall morbidity (26% vs 33%; P = 0.01), shorter hospital stays (7 vs 8 days; P < 0.01), fewer readmissions (20% vs 27%; P = 0.01), and lower rates of grade ≥3 pancreatic fistula (16% vs 20%; P = 0.05). Similar reoperation (both <1%), interventional radiology procedures (15% vs 19%; P = 0.1), and mortality rates (2% vs 1%; P = 0.3) were seen in both groups. There were no differences between the routine drainers group (n = 248) and the nondrainers group (n = 478) in grade ≥3 fistula or need for interventional radiology-guided procedures.

CONCLUSIONS

In this study, operative drains were used nearly half of the time and were associated with longer hospital stay, and higher grade ≥3 morbidity, fistula, and readmission rates. They did not decrease the need for reintervention or alter mortality rates. Routine prophylactic drainage after pancreatic resection could be safely abandoned.

Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience)

BACKGROUND

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers.

METHODS

This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected.

RESULTS

A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m(2) (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter <3 mm (0.0001), pancreatic duct located <3 mm from the posterior border (P = 0.02) were significantly associated with POPF. With the multivariate analysis, both BMI and pancreatic duct diameter were demonstrated to be independent factors. The hospital mortality in this series was 11 patients (2.3 %), and the development of POPF type C was associated with a significantly increased mortality (7/14 patients). The following factors were predictors of clinically evident POPF: a postoperative day (POD) 1 and 5 drain amylase level >4,000 IU/L, WBC, pancreatic duct diameter <3 mm, and pancreatic texture.

CONCLUSIONS

Cirrhotic liver, BMI, soft pancreas, pancreatic duct diameter <3 mm, pancreatic duct near the posterior border are risk factors for development of POPF. In addition a drain amylase level >4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.

Diagnostic value of abdominal drainage in individual risk assessment of pancreatic fistula following pancreaticoduodenectomy

Background

The use of prophylactic abdominal drainage following pancreaticoduodenectomy (PD) is controversial as its therapeutic value is uncertain. However, the diagnosis of postoperative pancreatic fistula (POPF), the main cause of PD-associated morbidity, is often based on drain pancreatic amylase (DPA) levels. The aim of this study was to assess the predictive value of DPA, plasma pancreatic amylase (PPA) and serum C-reactive protein (CRP) for diagnosing POPF after PD.

Methods

Patients undergoing PD with prophylactic drainage between 2008 and 2012 were studied prospectively. DPA, PPA and CRP levels were obtained daily. Differences between groups with clinically relevant POPF (International Study Group on Pancreatic Fistula (ISGPF) grade B/C) and without clinically relevant POPF (no POPF or ISGPF grade A) were evaluated. Receiver operating characteristic (ROC) analyses were performed to determine the value of DPA, PPA and CRP in prediction of POPF. Risk profiles for clinically relevant POPF were constructed and related to the intraoperative pancreatic risk assessment.

Results

Fifty-nine (18·7 per cent) of 315 patients developed clinically relevant POPF. DPA, PPA and CRP levels on postoperative day (POD) 1–3 differed significantly between the study groups. In predicting POPF, the DPA level on POD 1 (cut-off at 1322 units/l; odds ratio (OR) 24·61, 95 per cent confidence interval 11·55 to 52·42) and POD 2 (cut-off at 314 units/l; OR 35·45, 14·07 to 89·33) was superior to that of PPA on POD 1 (cut-off at 177 units/l; OR 13·67, 6·46 to 28·94) and POD 2 (cut-off at 98 units/l; OR 16·97, 8·33 to 34·59). When DPA was combined with CRP (cut-off on POD 3 at 202 mg/l; OR 16·98, 8·43 to 34·21), 90·3 per cent of postoperative courses could be predicted correctly (OR 44·14, 16·89 to 115·38).

Conclusion

The combination of serum CRP and DPA adequately predicted the development of clinically relevant pancreatic fistula following PD.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

AIM: To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis.

METHODS: We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patient’s score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate.

RESULTS: Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT.

CONCLUSION: Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Establishment of a simple predictive scoring system for pancreatic fistula after laparoscopy-assisted gastrectomy

BACKGROUND

The potential severity of postoperative pancreatic fistula (POPF) after laparoscopy-assisted gastrectomy (LAG) necessitates efforts to identify predictive factors for POPF. The aim of the present study was to identify predictive factors for POPF and to establish a predictive scoring system for POPF after LAG.

PATIENTS AND METHODS

Between June 2004 and March 2011, 277 gastric cancer patients who underwent curative resection with LAG were enrolled. POPF was defined according to the International Study Group for Pancreatic Fistula grading system. Risk factors for POPF were evaluated using logistic regression analysis, and a scoring system for POPF was established.

RESULTS

In the derivation cohort, multivariate analysis revealed the risk factors for POPF as patient age ≤70 years (5 points), amylase level of postoperative day 1 drainage fluid >454 IU/L(5 points), total number of retrieved lymph nodes >21 (5 points), body mass index >21.45 kg/m(2) (4 points), and operating time >337 min (2 points). In the validation cohort, at the cut-off point for high risk (score ≥15), the model had a negative predictive value of 94.5%, a positive predictive value of 57.4%, a sensitivity of 88.6%, and a specificity of 75.0% (C statistic = 0.857).

CONCLUSION

This study demonstrated that POPF after LAG is associated with specific preoperative and postoperative factors. With a simple predictive scoring system, patients at high risk for POPF can be accurately identified. This simple predictive scoring system will be useful for many clinicians to assess the risk of POPF after LAG and start treating at-risk patients earlier.

Schematic pancreatic configuration: a risk assessment for postoperative pancreatic fistula after pancreaticoduodenectomy

INTRODUCTION

Postoperative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). Preoperative risk assessment of POPF is desirable in careful preparation for operation. The aim of this study was to assess simple and accurate risk factors for clinically relevant POPF based on a schematic understanding of the pancreatic configuration using preoperative multidetector computed tomography.

METHODS

Three hundred and eighteen consecutive patients who underwent PD in the National Cancer Center Hospital East between November 2006 and March 2013 were investigated. Pre-, intra-, and postoperative clinicopathological findings as well as pancreatic configuration data were analyzed for the risk of clinically relevant POPF. POPF was defined according to the International Study Group of Pancreatic Fistula classification. POPF grade A occurred in 52 patients (16.4%), grade B in 84 (26.4%), and grade C in 6 (1.9%).

CONCLUSIONS

Independent risk factors for POPF grade B/C included main pancreatic duct diameter (MPDd) < 2 mm (P = 0.001), parenchymal thickness ≥ 8 mm (P = 0.018), not performing portal vein/superior mesenteric vein resection (P = 0.004), and amylase level of drainage fluid on postoperative day 3 ≥ 375 IU/L (P < 0.001). Pancreatic configuration data including MPDd and parenchymal thickness were good indicators of clinically relevant POPF.

Drainage volume after pancreaticoduodenectomy is a warning sign of chyle leakage that inversely correlates with a diagnosis of pancreatic fistula

BACKGROUND

Chyle leakage is a rare complication of pancreaticoduodenectomy (PD), and its association with pancreatic fistula has not been established. The aim of this study was to (1) evaluate the incidence, management, and risk factors of chyle leakage after PD; (2) determine if there is a relation between chyle leakage and diagnosis of pancreatic fistula; and (3) predict chyle leakage with drainage volume early.

METHODS

A total of 222 patients underwent PD or pylorus-preserving PD. We used the clinical database registry system of the Gangnam Severance Hospital, Yonsei University Health System to establish a retrospective cohort with clinicopathologic data.

RESULTS

Altogether, 24 patients (10.8 %) developed chyle leakage. Chyle leakage was identified at a median 5 days after surgery and a mean 2 days after enteral intake. The mean drain triglyceride level was 315 mg/dl. Early enteral intake was independently associated with chyle leakage. Chyle leakage was inversely correlated with a diagnosis of pancreatic fistula with marginal significance (odds ratio 0.27; 95 % confidence interval 0.66-1.09). The receiver operating characteristic curve of the volume on postoperative day 4 demonstrated an area under the curve of 0.740 (p = 0.0001). Drainage >335 ml indicated possible chyle leakage.

CONCLUSIONS

Chyle leakage after PD is associated with early enteral intake. It was inversely correlated with a diagnosis of pancreatic fistula because of the dilution effect of drainage volume on the concentration of drained amylase. Because early diagnosis helps with appropriate management, prediction/suspicion of chyle leakage based on drainage volume may be useful.

Multivariate logistic regression analysis for prediction of clinically relevant pancreatic fistula in the early phase after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (PF) remains a major complication after pancreaticoduodenectomy (PD). We aimed to investigate the predictors of clinically relevant PF after PD.

METHODS

We retrospectively analyzed the predictive factors of relevant grade B/C PF using logistic regression analysis of 100 consecutive patients who underwent PD. PF was defined in accordance with the International Study Group on PF (ISGPF).

RESULTS

White blood cell count (WBC) of 73.6 × 10(2) /μl, C-reactive protein (CRP) of 9.3 mg/dl and amylase value in drains (d-amylase) of 647 U/I on postoperative day (POD) 4 were proposed as the cut-off values for predicting grade B/C PF with high accuracy by the receiver operating characteristic (ROC) curve. Multivariate logistic regression analysis revealed that the three factors as significant predictive factors and the predicted probability of detecting grade B/C PF was calculated by the following formula; P = 1/[1 + exp{-(2.033 × WBC+3.269 × CRP+2.698 × d-amylase-4.122)}]. P > 0.5 indicates the prospective incidence of the PF. When the cut-off values of the three significant predictors were substituted into the formula, P always showed above 0.5 if more than two predictors were above their cut-off values, indicating a high probability of grade B/C PF.

CONCLUSIONS

White blood cell count, CRP and d-amylase on POD4 were predictive factors for clinically relevant PF after PD. These findings indicate that our formula is useful for management of drain after PD.

Visualization of the leakage of pancreatic juice using a chymotrypsin-activated fluorescent probe

BACKGROUND

Pancreatic fistula (PF) remains the most serious complication after digestive surgery. It is difficult to prevent because of the inability to visualize the leakage of pancreatic juice during surgery or to evaluate the protease activity of leaked fluid, which is responsible for PF formation.

METHODS

The fluorescence intensities of a chymotrypsin probe (glutaryl-phenylalanine [corrected] hydroxymethyl rhodamine green with added trypsin) in pancreatic juice and in intestinal or abdominal fluids drained after pancreatic resection were evaluated. The chymotrypsin probe was sprayed on to filter papers that had been placed on the resected pancreatic stump in patients undergoing pancreaticoduodenectomy or central pancreatectomy. The ability of this technique to visualize the leakage of pancreatic juice and predict postoperative PF formation was assessed.

RESULTS

The fluorescence intensity of the chymotrypsin probe in 76 fluid samples correlated positively with amylase levels (r(s) = 0.678, P < 0.001). The fluorescence patterns of the pancreatic stump were classified grossly into the three types: duct (fluorescence signal visualized only on the stump of the main pancreatic duct, 16 patients), diffuse (ductal stump and surrounding pancreatic parenchyma, 7) and negative (no fluorescence signal, 7). Symptomatic PFs developed in 13 of 23 patients with duct- or diffuse-type fluorescence, but in none of the seven patients with negative-type fluorescence (P = 0.008).

CONCLUSION

The chymotrypsin probe enabled determination of the protease activity in drained pancreatic fluid samples and allowed real-time visualization of pancreatic juice leakage during surgery.

Complications after pancreatic resection: diagnosis, prevention and management

BACKGROUND

Although mortality after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has decreased, morbidity still remains high. The aim of this review article is to present, define, predict, prevent, and manage the main complications after pancreatic resection (PR).

METHODS

A non-systematic literature search on morbidity and mortality after PR was undertaken using the PubMed/MEDLINE and Embase databases.

RESULTS

The main complications after PR are delayed gastric emptying (DGE), pancreatic fistula (PF), and bleeding, as defined by the International Study Group on Pancreatic Surgery. PF occurs in 10% to 15% of patients after PD and in 10% to 30% of patients after DP. The different techniques of pancreatic anastomosis and pancreatic remnant closure do not show significant advantages in the prevention of PF, nor does the perioperative use of somatostatin and its analogues. The trend is for conservative or interventional radiology therapy for PF (with enteral nutrition), which achieves a success rate of approximately 80%. DGE after PD occurs in 20% to 50% of patients. Prophylactic erythromycin may reduce the incidence of DGE. Gastric aspiration with erythromycin is usually effective in one to three weeks. Bleeding (gastrointestinal and intraabdominal) occurs in 4% to 16% of patients after PD and in 2% to 3% of patients after DP. Endovascular treatment can only be used for a haemodynamically stable patient. In cases of haemodynamic instability or associated septic complications, surgical treatment is necessary. In expert centres, the mortality rates can be less than 1% after DP and less than 3% after PD.

CONCLUSION

There is a need for improved strategies to prevent and treat complications after PR.

Is it time to abandon routine operative drain use? A single institution assessment of 709 consecutive pancreaticoduodenectomies

BACKGROUND

Routine use of operative (primary) drains after pancreaticoduodenctomy (PD) remains controversial. We reviewed our experience with PD for postoperative (secondary) drainage and postoperative pancreatic fistula (POPF) rates based on use of primary drains.

STUDY DESIGN

We identified consecutive patients who underwent PD between 2005 and 2012 from our pancreatectomy database. Primary closed suction drains were placed at the surgeon's discretion. Patient and operative factors were assessed, along with POPF, complications, and secondary drain placement rates.

RESULTS

There were 709 PDs performed, and 251 (35%) patients had primary drains placed. Age, sex, body mass index, and comorbidities were similar among groups; however, drained patients had slightly larger pancreatic ducts (mean diameter 3.8 mm vs 2.2 mm; p < 0.01). The overall secondary drainage rate was 7.1%. Primary drain placement did not affect the need for secondary drainage (with primary drain, 8.4% vs without primary drain 6.3%, p = 0.36), reoperation (5.6% vs 5.7%, p = 1.00), readmission (17.5% vs 16.8%, p = 0.89), or 30-day mortality (2.0% vs 2.5%, p = 0.80). When compared with the no drain group, patients with primary drains experienced higher rates of overall morbidity (68.1% vs 54.1%, p < 0.01) and significant POPF (16.3% vs 7.6%; p < 0.01), as well as longer hospital stays (13.8 days vs 11.3 days; p < 0.01). On multivariate analysis, primary drain placement remained an independent risk factor for pancreatic fistula formation (hazard ratio 3.3, p < 0.01), but did not have an impact on secondary drainage rates (p = 0.85).

CONCLUSIONS

Placement of closed suction drains during pancreaticoduodenectomy does not appear to decrease the rate of secondary drainage procedures or reoperation, and may be associated with increased pancreatic fistula formation and overall morbidity. These data support foregoing routine primary operative drainage at time of pancreaticoduodenectomy.

Defining treatment and outcomes of hepaticojejunostomy failure following pancreaticoduodenectomy

BACKGROUND

The overall complication rate after pancreaticoduodenectomy (PD) approaches 50 %, with anastomotic failure being the most frequent cause of serious postoperative morbidity. Hepaticojejunostomy leaks (also called bile leaks) are the second most common type of leak, behind pancreaticojejunostomy leaks, yet have been the focus of only a single study as reported by Suzuki et al. (Hepatogastroenterology 50:254-257, 12).

METHODS

We reviewed the recent experience with bile leaks at a single, high-volume pancreatic surgery center over a six-year time period.

RESULTS

Bile leaks were identified in 16 out of 715 patients (2.2 %). Low preoperative albumin was associated with an increased risk. Bile leaks typically manifested within the first week after surgery as bilious drainage in a surgically placed drain. Associated warning signs included fever and leukocytosis. Patients with a bile leak frequently developed other complications, including a pancreatic fistula, wound infection, delayed gastric emptying, and sepsis. The impact on perioperative outcomes was comparable to patients with a pancreatic leak. A grading system is proposed based on the International Study Group on Pancreatic Fistula model. Grade A bile leaks were classified as those managed with prolonged drainage by operatively placed drains, grade B bile leaks with percutaneous abdominal drainage, and grade C bile leaks with insertion of a percutaneous transhepatic biliary drainage.

CONCLUSIONS

Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening and is comparable overall to pancreaticojejunostomy leaks. Surgical intervention is rarely, if ever, required. With prompt and aggressive management, a full recovery can be expected.

Efficacy of an absorbable fibrin sealant patch (TachoSil) after distal pancreatectomy: a multicenter, randomized, controlled trial

OBJECTIVE

To evaluate the role of an absorbable fibrin sealant patch (TachoSil) in reducing postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP).

BACKGROUND

POPF remains the main complication after DP.

METHODS

This was a prospective, open, randomized, study in which patients undergoing elective DP were randomized to standard surgical suturing or stapling with or without TachoSil. The primary end point was the incidence of POPF according to International Study Group on Pancreatic Fistula criteria. Amylase level in drainage fluid, number of days until removal of drain, and duration of hospital stay were secondary end points.

RESULTS

A total of 275 patients were enrolled at 19 centers over a 2-year period (TachoSil, n = 145; standard, n = 130). Twenty percent of procedures were laparoscopic and 21% were spleen-preserving resections. The incidence of POPF was not significantly different between groups (TachoSil, 62%; standard 68%; P = 0.267). Grade A fistula rate was similar in both groups (TachoSil 54%; standard 55%), whereas the grade B + C fistula rate was 8% with TachoSil versus 14% without (P = 0.139). Amylase drainage level on postoperative day 1 was significantly reduced with TachoSil (P = 0.025). Median number of days until drainage removal and length of hospital stay were similar in both groups (7 and 10 days, respectively).

CONCLUSIONS

The POPF rate was higher than expected when International Study Group on Pancreatic Fistula criteria were strictly applied, although the majority were biochemical fistulas. TachoSil had no significant effect on the rate of POPF, although there was a significant reduction of amylase level in drainage fluid on postoperative day 1.

Pancreatoenteral anastomosis or direct closure of the pancreatic remnant after a distal pancreatectomy: a single-centre experience

BACKGROUND

A major complication of a distal pancreatectomy (DP) is the formation of a post-operative pancreatic fistula (POPF). In spite of the utilization of numerous surgical techniques no consensus on an appropriate technique for closure of the pancreatic remnant after DP has been established yet. The aim of this study was to analyse the impact of pancreatoenteral anastomosis (PE) vs. direct closure (DC) of the pancreatic remnant on POPF.

METHODS

A total of 198 consecutive patients who underwent a distal pancreatectomy between 2002 and 2010 at our institution were retrospectively analysed for post-operative morbidity and mortality.

RESULTS

One hundred and fifty-one patients (76.3%) received DC whereas PE was performed in 47 patients (23.7%). The incidence of POPF was higher in the DC group (22% vs. 11%), whereas the rate of post-operative haemorrhage was higher in the PE group (11% vs. 7%). However, these differences were not significant. Additionally, there were no significant differences in overall post-operative morbidity and mortality between the groups.

CONCLUSIONS

The performance of PE instead of DC may be considered as a safe alternative in individual patients, but it does not significantly lead to a general improvement in post-operative outcome after DP. An interdisciplinary collaboration in the prevention and treatment of POPF therefore remains essential.

Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review

INTRODUCTION

The terms ‘enhanced recovery after surgery’, ‘enhanced recovery programme’ (ERP) and ‘fast track surgery’ refer to multimodal strategies aiming to streamline peri-operative care pathways, to maximise effectiveness and minimise costs. While the results of ERP in colorectal surgery are well reported, there have been no reviews examining if these concepts could be applied safely to hepatopancreatobiliary (HPB) surgery. The aim of this systematic review was to appraise the current evidence for ERP in HPB surgery.

METHODS

A MEDLINE® literature search was undertaken using the keywords ‘enhanced recovery’, ‘fast-track’, ‘peri-operative’, ‘surgery’, ‘pancreas’ and ‘liver’ and their derivatives such as ‘pancreatic’ or ‘hepatic’. The primary endpoint was length of post-operative hospital stay. Secondary endpoints were morbidity, mortality and readmission rate.

RESULTS

Ten articles were retrieved describing an ERP. ERP protocols varied slightly between studies. A reduction in length of stay was a consistent finding following the incorporation of ERP when compared with historical controls. This was not at the expense of increased rates of readmission, morbidity or mortality in any study.

CONCLUSIONS

The introduction of an ERP in HPB surgery appears safe and feasible. Currently, many of the principles of the multimodal pathway are derived from the colorectal ERP and distinct differences exist, which may impede its implementation in HPB surgery.

Perioperative management of patients undergoing pancreatic resection: implementation of a care plan in a tertiary-care center

Evidence-based perioperative management is important for a successful outcome after pancreatic surgery. Use of protocolized pathways of care based on fast-track concepts has been shown to reduce hospital stay and contain costs. These regimens include pain control, early device removal (nasogastric tube, abdominal drains), enforced early mobilization, and early oral feeding. In this article, current evidence on perioperative management of pancreatic resections was analyzed in the attempt to implement our institutional care plan.

Risk factors for postoperative pancreatic fistulization subsequent to enucleation

INTRODUCTION

Pancreatectomies increase the risk of postoperative pancreatic fistula (POPF) and pancreatic insufficiency. Pancreatic enucleation preserves pancreatic parenchyma, lowers the risk of pancreatic insufficiency, but may induce specific complications (tumor recurrence or pancreatic fistulization). The aim of this study was to determine the risk factors for POPF following a pancreatic enucleation.

METHODS

A retrospective analysis was designed based on data from patients who underwent pancreatic enucleation in five university hospitals (1998-2008). The presence of a pancreatic fistula was determined according to the criteria of the International Study Group of Pancreatic Fistula (Bassi et al. Surgery 138:8-13, 2005).

RESULTS

Fifty-two patients (mean age 52 years) were included. Histological analysis revealed 35 endocrine tumors (68.6 %), 6 mucinous and 2 serous cyst adenomas, 2 metastases of renal cancer, and 8 benign tumors. Nineteen patients (36.5%) suffered postoperative complications including 14 POPF (27 %). Median postoperative hospital stay was 12.9 days; 9.1 days without POPF versus 29 days with POPF (p < 0.05). Size of the tumor, its location, histological differentiation, and use of somatostatin analogs were not predictors for POPF. We defined the cutoff for POPF at a distance of 2 mm from the main pancreatic duct based on 60% risk (≤2 mm) versus 19 % (>2 mm) of POPF (p < 0.01). With a mean follow-up of 30.8 months, one patient experienced recurrence of the tumor. No patients exhibited a new onset of diabetes or pancreatic insufficiency.

CONCLUSION

Enucleation for resection of pancreatic tumors located at less than or equal to two 2 mm from the main pancreatic duct is a risk factor for POPF. Enucleation is a safe and effective treatment for benign or borderline pancreatic tumors.

Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy

OBJECTIVE

To assess the influence of body fat distribution, estimated by a preoperative computed tomographic (CT) scan, on pancreatic fistula (PF) risk after pancreaticoduodenectomy (PD).

BACKGROUND

Pancreatic fatty infiltration is a predictive factor of PF, but accurate preoperative assessment is challenging. We hypothesized that it could be associated with an increased visceral obesity and could be assessed preoperatively.

METHODS

Over 18 months, 103 consecutive patients with PD and pancreaticogastrostomy were studied. Demographic, radiologic, and pathologic data were correlated to PF occurrence. Radiologic data included on a nonenhanced CT acquisition: pancreas, spleen, and liver density measures (Dpancreas, Dspleen, and Dliver [densities of the pancreas, spleen, and liver in hounsfield units], respectively), retro-renal fat thickness, and at the level of the umbilicus, total, visceral, and subcutaneous fat area (TFA [total fat area], VFA [visceral fat area], and SFA [subcutaneous fat area], respectively). Pancreatic fatty infiltration was graded histologically. Logistic regression analysis was used to identify independent predictors of PF-graded B and C according to the International Study Group on the Pancreatic Fistula.

RESULTS

Among the 103 patients, 37% (n = 38) developed a PF (47.4% grade A, 39.5% grade B, and 13.1% grade C). PF risk was correlated with pancreatic fatty infiltration (P = 0.017). In univariate analysis, male gender (P = 0.023), body mass index (BMI) over 25 kg/m (P = 0.02), retro-renal fat thickness over 15 mm (P = 0.006), TFA over the median (>233 cm; P = 0.023), and VFA over the median (>84 cm; P < 0.0001) were significantly associated with an increased risk of symptomatic PF (grade B and C). In multivariate analysis, VFA greater than 84 cm (OR = 8.16, P = 0.002) was the only independent predictive factor of grade B or C PF. Using the same model, a VFA greater than 84 cm was the only independent factor associated with the presence of fatty pancreas on pathologic examination.

CONCLUSIONS

Preoperative assessment of body fat distribution by a CT scan, as a surrogate for fatty pancreas infiltration, can help to predict the occurrence of clinically significant PF after PD.